Encouraging positive mental health discussion
It’s mental health month and 10 October is the start of Mental Health Week. The Mental Health Australia 2020 campaign asks us to challenge our perceptions of mental illness and encourages us all to view mental illness in a more positive way. Here are ways physiotherapists can proactively help their patients.
A positive view of mental illness is a way to reduce stigma for those experiencing mental health problems and make it easier to ask for help.
Sadly, healthcare workers are not exempt from having prejudiced or negative stereotypes about people with mental health problems (MacNeela et al 2012), and the resulting stigma can impact negatively on the healthcare worker’s interaction with patients (O’Reilly et al 2011).
Mental health literacy, learning to recognise mental health problems, risk factors and appropriate treatments are an important element of improving perceptions of mental illness and mental health problems (Jorm et al 2005).
Avoiding talking about mental health problems increases stigma, and talking to someone about your concerns for their mental health helps to reduce stigma (SANE Australia 2019).
Unfortunately, many healthcare workers believe they lack skills to talk with people about their mental health problems and feel uncomfortable raising the issue of mental health problems for fear of upsetting the person (Arvaniti et al 2009).
This means they do not discuss their concerns about observed behaviours that suggest the person is not mentally healthy, nor offer to support them to seek appropriate help.
Physiotherapists are good communicators. We are comfortable discussing behaviours that might suggest a person has bowel or bladder continence issues and we will gladly discuss sputum, paralysis, misconceptions about pain, falls and balance issues, impairments and many more ‘delicate’ topics.
Physiotherapists will raise and discuss strategies on how to properly address these problems if we believe they are impacting on the person’s overall wellbeing and recovery.
We have skills to talk about what many perceive as difficult or taboo subjects. Why, then, is there a perceived barrier to talking about mental health?
A lack of confidence in our mental health literacy may explain our reluctance to talk about mental health issues and mental illness (Connaughton & Gibson 2016).
A better understanding of mental health problems and knowing where to direct the person to ensure they receive appropriate care has been shown to build confidence in physiotherapy students to engage with people with mental illness (Edgar & Connaughton 2020).
Anxiety disorders and depression are the two most prevalent mental health problems in Australia. This article will explore signs and symptoms of these two conditions and include a focus on the anxiety disorder, post-traumatic stress disorder (PTSD).
We will explain a little about how these symptoms may impact on your therapeutic interactions and then focus on helpful communication strategies.
Finally, we have provided a shortlist of accessible and reliable resources with information on where to direct someone to access help.
Recognising signs of anxiety disorder
We all experience some signs and symptoms of anxiety or stress in response to a perceived threat.
This is a natural response to a real or perceived threat, and from an evolutionary perspective has been essential to our survival.
We need to be able to fight or flee from danger. Anxiety, or a sustained stress response, becomes a problem when it is severe, long lasting and impacts on our ability to go about our day-to-day activities.
For some people, visiting a physiotherapist can evoke symptoms of anxiety, regardless of how welcoming and non-threatening the environment.
It is normal to feel anxious in a new situation, so when seeing a new patient, if they have a comorbid anxiety disorder, they may appear excessively fearful or worried about the appointment.
This may be even more evident in the person with PTSD, as discussed shortly. This excessive fear or worry is not a reflection on you, rather a reflection on anxiety around the unknown.
An anxious person’s symptoms may include a racing mind or going blank, having difficulty concentrating or remembering. People experiencing these symptoms may struggle to answer questions during a subjective examination, or have difficulty relaying the history of their condition.
It is important to give the person time to think and formulate their answers without interruption or any signs of frustration.
We can all appreciate how hard it is to concentrate when we are sleep deprived. A person with an anxiety disorder may experience ongoing disturbed sleeping patterns and have even more trouble focusing on questions and formulating replies.
It is important to ask about sleeping patterns and determine the cause, because the knowledge will affect both your interaction with the person and your treatment plan.
If your patient advises you they are not sleeping well, it is important to ask why. Is this sleep disturbance related to their presenting pain or physical condition or is there another reason—is it related to an anxiety disorder?
The physical manifestations of anxiety may include muscle aches and pains.
A person with anxiety disorder may have an altered perception of musculoskeletal problems they are experiencing and may not respond as expected to your treatment program and subsequent recovery.
Aches and pains associated with anxiety disorder are real physical symptoms and should not be disregarded.
It is important to acknowledge you have heard and believe the presence of these pains; however, it is important to emphasise what outcomes might be expected from your treatment, and that not all aches and pains may be eliminated.
Recognising signs of PTSD
PTSD can occur when a person has been exposed to or witnessed traumatic events.
Everyone’s perception of a traumatic event is different so what one person perceives as traumatic, another may not. It is not for us to judge what constitutes a traumatic event for another person.
Not everyone who has experienced a traumatic event will develop PTSD but each person’s predisposition and comorbid conditions impact on their vulnerability to develop the condition.
For many people who experience PTSD a situation, memory, sound, smell or other trigger may cause them to relive the situation, resulting in increased emotional distress.
Asking a person with PTSD to retell the history of their injury may trigger an anxiety response.
Sometimes it is easy to recognise risk factors for PTSD. For example, we know that some workers such as trauma nurses, paramedics and military personnel have an increased risk of developing PTSD by repetitive exposure to stressful events in the workplace.
However, in many cases the risk factors may be less obvious. It is the patient’s history, behaviour or comments that may alert you to the possibility that they have PTSD.
For the person with PTSD, associated mental health issues may delay injury management.
Looking out for possible signs and symptoms of PTSD as described in the adjacent text box is important. It is equally important to recognise that some of the consequences of persistent PTSD may be the only clue to the presence of it.
Many times these consequences are attributed to a person being difficult or lazy.
Yellow flags such as an aversion to return to work, increase in absenteeism or compassion fatigue, burnout or mental exhaustion can hinder recovery. It is not enough to note these behaviours then disregard them; they need to be explored for the presence of PTSD so appropriate intervention can be implemented.
PTSD is a complex disorder that requires a multidisciplinary team for optimal management.
As physiotherapists, we play an important role in this management provided we understand the complexity of how patients may present. It is essential to recognise any injury can have physical and emotional consequences and remember that physical pain affects emotional coping, and vice versa.
The physiology of PTSD and pain are better understood now in terms of the cognitive, emotional and physical response to injury (Steptoe et al 2009).
Traditional management for PTSD includes pharmacological and cognitive therapy; however, residual symptoms can remain.
Exercise with mindfulness and deep breathing (ie, yoga, tai chi) as well as relaxation training have proved protective against stress-related health problems (Sang Hwan Kim et al 2013).
What is major depressive disorder? Everyone has experienced sadness when bad things happen. This is a normal response, but it is not a depressive disorder.
Major depressive disorder is distressing, lasts for at least two weeks and impacts on a person’s ability to go about their normal activities. A person with a depressive disorder may be slow in their movements, speech and thinking, and these symptoms can affect the therapeutic relationship between physiotherapist and patient.
Changes in the prefrontal cortex and executive functioning centres of the brain as a result of prolonged depressive disorder may mean a person has difficulty concentrating.
As with anxiety, someone with a depressive disorder may find subjective examinations challenging and require extra time to comprehend the questions and formulate an answer.
Failure to give a person this extra time, and/or showing impatience while waiting for an answer, may compound feelings of worthlessness or guilt. Likewise, becoming impatient if a person is slow moving during subjective examination can reinforce feelings of worthlessness.
When creating a treatment program for someone with depressive disorder, including home exercise programs, it is important to account for the symptoms that person may be experiencing.
As caring people, physiotherapists want to improve the life of their patients, not exacerbate any negative feelings they may be experiencing.
Overloading a person with complex and numerous home exercises may set them up for failure and further fuel those feelings of guilt and worthlessness. Keep programs manageable.
Communication is key
Good communication with people who have mental health problems is essential to reduce stigma.
Good communication skills are key to achieving patient satisfaction, patient recall and understanding, symptom resolution, adherence to treatment and improved psychological outcomes (Julius et al 2009).
Communication skills are core clinical skills that can profoundly impact a patient’s experience and how they manage their health after they leave our care (ACSQHC 2015).
There are four main types of communication we use— verbal, nonverbal, written and visual. Below we discuss some verbal and nonverbal strategies and some tips in relation to mental health problems.
Respect through active listening
Listening is the most important skill and often the most challenging because it requires not talking.
Listening is not doing nothing, but rather giving someone the space to tell their story, be heard and feel cared for.
Listening helps people feel less isolated and gives them an opportunity to make sense of what is going on, which can be difficult when the mind is occupied by worry or rumination.
Active listening means giving full attention to the words and the nonverbal cues of body language, facial expression and voice tone, while at the same time dropping our own ‘assumed’ judgements.
Acknowledgement through reflecting
Reflecting is the process of restating both the words and the feelings of the patient and ‘reflecting’ it back.
It allows the patient to ‘hear’ their own thoughts, perhaps think about it and continue their story or decide to tell it in a different way. It shows the patient that we are listening and trying to see the world from their perspective.
Understaning through paraphrasing and summarising
No matter how well we listen, the patient is the only one who can tell us if we have understood them, or if they understand us.
Paraphrasing is a form of reflecting where we use our own words to reflect the patient’s message and move the conversation gently forward. It can involve more complex reflections which include feelings and meaning.
In the example above we could say ‘You are not going out because your knees hurt and it is starting to get you down’. Paraphrasing gives the client an opportunity to clarify and let us know if we have correctly picked up on the message.
Summarising is a longer form of paraphrasing and is useful when a person is in distress and has given a lot of information.
Summarising can be done along the way, to check the message and act as a natural pivot point, at the end of a session as a wrap-up and at the beginning of the next session.
Summarising helps people who are having trouble with focusing and have memory difficulties. Asking the client to paraphrase and summarise back to us is a good way to check understanding of information.
Connecting through questioning
Closed questions can be answered with a single word or short phrase. They are easy and quick to answer and are useful when gathering facts.
Closed questions are limited but can help when a person is feeling overwhelmed and struggling to answer. In the same way, single questions are easier to answer than multiple questions.
Open questions, starting with ‘who’, ‘what’, ‘how’, ‘when’ and ‘where’ invite dialogue and are person-centred. Open questions are a good way to refer to a person’s mental health issues, as in ‘What impact does feeling down have on your physical activity?’, or ‘What would you like me to know about your PTSD, which would be helpful in us working together?'
Empowering through informing
Educating, informing and passing on information is part of what we do as practitioners.
People experiencing cognitive, emotional and/or physiological overwhelm can benefit from simplified instructions and explanations, patient-centred SMART goals and specifics in terms of exercise frequencies and intensities (Connaughton 2018).
Other helpful strategies include mirroring with our own bodies, guiding the movement with our hands and giving continuous and immediate feedback. Written and visual aids help to consolidate information and reduce stress relating to poor memory. ***
Noticing through nonverbal
Much of the communication between people is body language which includes eye contact, facial expressions, voice, body movements and physiological responses.
It is important to be aware of our own body language and how we can use it for more effective connection. Psychologist Gerard Egan (2010) created the acronym SOLER to define a nonverbal listening process:
S - sit squarely on, preferably at 5 o’clock position, to avoid staring and intimidating
O - maintain an open posture, not crossing arms or legs
L - lean slightly forward
E - at times maintain eye contact, without staring
R - be as relaxed as possible.
At the same time, it’s good to be aware of not over- interpreting the body language of another.
It is okay to check-in, as in, ‘I noticed you started fidgeting when I talked about a walking program. How do you feel about walking?’
Touch is another form of nonverbal communication.
It can be procedural, as in part of the therapeutic intervention or non-procedural, as in patting someone’s hand. At this time of heightened uncertainty and concern regarding infectious control, it is especially important to follow all hygiene control regulations, explain the rationale of any required touch, and ask and obtain permission. ***
How can I help?
It is one thing to raise concerns about mental health problem but it is also important to be able to offer some advice on how to access help.
Physiotherapists may be able to recognise signs and symptoms of mental illness and hopefully discuss any concerns, but we cannot treat mental illness. Looking for resources can be an overwhelming exercise.
The following resources may be useful for you to pass on to those you believe may benefit. Most of these are also resources you can access for more information about working with someone who is experiencing a mental health problem.
General practitioner: A GP can prescribe medication if required, explore for physical causes of the symptoms, refer the person to a psychologist for treatment or a psychiatrist if symptoms are severe.
Beyondblue: the Beyondblue website has a checklist for self-assessment, information sheets on anxiety and depressive disorders, and a 24-hour helpline that gives information on services and how to access them.
HeadtoHealth: this is an Australian government website that has information for people living with mental health problems as well as for carers and healthcare workers. It provides access to some online therapy programs and has factsheets. ***
Black Dog Institute: the Black Dog Institute has useful information on bipolar disorder.
MoodGYM: this website describes itself as ‘like an interactive self-help book which helps you learn and practise skills which can help to prevent and manage symptoms of depression and anxiety’.
Phoenix Australia: the Australian National Centre for excellence in post-traumatic stress, Phoenix Australia webpage has information for people living with PTSD as well as for health practitioners.
Person-centred in every respect
Physiotherapy approaches that are person-centred and respect diversity will address stigma and discrimination.
The trials of 2020—fires, floods and pandemic—have truly tested the mental health of all Australians and highlighted the need to take a truly person-centred approach to each and every person we assess and treat in our daily work.
Now is the time to remember that every person has a body and a mind.
Now is the time to recall the complex interaction between mental and physical health.
Now is the time to challenge the stigmas associated with mental health.
Now is the time to speak freely of the impacts of mental health on wellbeing and recovery.
Now is the time to walk the walk and talk the talk.
© Copyright 2018 by Australian Physiotherapy Association. All rights reserved.